SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
CONTACT THE SLU CME OFFICE AT FIRST STAGES OF PLANNING TO DETERMINE TIMEFRAME
FOR IMPLEMENTATION AND APPROVAL
GENERAL INFORMATION REGARDING APPROVAL OF CME/CE ACTIVITIES FOR CREDIT Types that
are joint provided through the Project Manager in the SLU CME OFFICE:
REMEMBER TO KEEP GOOD DOCUMENTATION OF ALL PLANNING MEETINGS. Planning notes will be
used to prove how you planned and implemented your activity without influence of commercial support.
Contact the CME office before your activity to reserve the date of your activity and ensure that no conflicts exist, schedule
support services, and obtain current forms and guidelines for implementation of your program. Major events; events
including 15 or more faculty or two or more days of educational learning require additional lead time.
SEE NEW FORMS CONCERNING DISCLOSURE AND CONFLICT OF INTEREST RESOLUTION. (Review the
dates in the footer of each form to ensure you are using the current approved document)
Review page 9-10 of the application to make sure you have completed all items necessary for review of your request.
Promotional materials and advertising (including invitations) must be approved by the SLU Accreditation
Representative (AMA credits, CME Office, Nursing credits, School of Nursing) and must be consistent with the CME
Promotional Guidelines. Promotional materials may not be distributed until the CME office has approved your program
and the proposed promotional items. Please route all material directly to the SLU CME Office. CME staff will determine
the correct person and route documents for review.
Validation of Program Content: Form must be completed by all planners and all presenters attesting that they
understand content and HIPAA regulations when compiling their presentations.
Definition of CME: The ACCME requires that activities approved for credits meet the definition of CME, which states:
“CME consists of educational activities which serve to maintain, develop, or increase the knowledge, skills and
professional performance and relationships that a physician uses to provide services for patients, the public, or the
profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession
as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.”
Further, an activity may not be eligible for CME credit if, in the judgment of the accredited provider, “The program is
devoted to advocacy of unscientific modalities of diagnosis or therapy.” The course director, with the guidance of the
CME office, is responsible for insuring that topics presented are eligible for CME credits. School of Nursing MONA
accreditation has similar language. We will do our best to combine this application so that one packet can be utilized for
review by all CME CE offerings at SLU. If something falls out of the guidelines of this application we will attach an
addendums for the section in question for type of credit your activity is seeking.
Off-Campus Events: All off site activities in the St. Louis area must be pre-approved by Event Services in order to
determine if there is available space at the University. If approved to go off site-SLU Departments must provide proof of
full external funding for off-campus activities prior to securing the conference site. All site contracts must be reviewed by
university purchasing and legal departments and signed by a legal representative of the university. You must attach a
letter attesting to the fact that your event will be self-supporting, listing what sources of income are anticipated and
requesting permission to hold the event at an off-campus facility at the time you submit your application.
Incomplete applications will not be accepted. Failure to comply with the above timeframe or CME Guidelines
may result in refusal of CME approval for credit.
Please type or complete electronically. Hand written applications will not be accepted. Highlighted areas are required sections.
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Sponsoring Department/Organization: ______________________________________________________
Activity Title: _________________________________________________________________________
Event Date: ____________________________________
Course Director:
Phone: _____________________________
E-Mail:_______________ Fax #:
Other Administrative Contact:
Phone: ___________________________
E-Mail:
Fax #:
Jointly Sponsored Activity: □ No □ Yes
If this activity is being sponsored by an organization not affiliated with Saint Louis University, please complete
the information below. If additional space is needed, attach a separate page.
Contact Name:
Title/Position: _______________________________
Organization Name: _____________________________________Phone:
Mailing address:
_____________________________________________________
E-mail___________________________
Web address:
Type of Activity:
□ Live Conference or Symposia
□ Web-Cast
□ Enduring Materials:
□ Monograph □ CD □ Web-based
□ Other
Event Location:________________________ □ On SLU Campus __________________________________
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Core Requirements, to be certified for CME/CE each activity must:
 Conform to the definition of the accrediting bodies requirements.
 Address demonstrated educational needs.
 Communicate to prospective participants a clearly identified educational purpose and/or objectives in
advance of participation in the activity.
 Be designed using approved learning formats and learning methodologies appropriate to the activity's
educational purpose and/or objectives; credit must be based on AMA guidelines for the type of learning
format used.
 Present content appropriate in depth and scope for the intended target audience.
 Be planned in accordance with the relevant CEJA opinions and the ACCME Standards for Commercial
SupportSM, and be non-promotional in nature. (ALL PLANNING MEMBERS DISCLOSURE
INFORMATION MUST BE COLLECTED DURING THE FIRST STAGE OF PLANNING. ALL
PLANNERS’ FORMS MUST BE SUBMITTED ALONG WITH THIS APPLICATION.) Please review
page two of the disclosure form for more information regarding who qualifies as a planning member for
this activity.
 Evaluate the effectiveness in achieving its educational purpose and/or objectives.
 Document credits claimed by attendees for a minimum of six years.
 Be certified for all credit types requested in advance of the activity; i.e. an activity may not be
retroactively approved for credit.
 Include the Appropriate Credit Designation Statement in any activity materials that reference CME/CE
credit with the exception of "save the date" or similar notices.
Target Audience: (Who will you promote your activity too? Who should be in attendance due to the
educational strategies you are teaching?)
_____________________________________________________________________________________
Other non-AMA credits: If you are seeking credits for other disciplines please let the CME staff know so
coordination of work can be discussed. Fees and application for these credits will be determined during the
planning session. The SLU CME Staff will act as the project managers and disseminate all documents to the
other schools for review and approval.
SLU CME Program holds the following accreditations:
 AMA through the ACCME (this application covers the credits for MD, DO, NP,PA-C) Course Director
should be an MD or DO and have input for every phase of planning and implementation

APA through the American Psychological Association (for Psychologist) Must have a psychologist for
every phase of planning and implementation in order to get approved for APA credits.

Nursing Home Administrators through the Missouri Board of Nursing Home Administrators (for NHA)
Provide description and objectives for each talk to prove relevance for NHA credits.

Physical Therapy and Occupational Therapy through the State of Illinois (for PT, PTA, OT, and OTA)
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Must have a physical therapist and occupational thearapist for every phase of planning and
implementation in order to get approved for PT/OT credits.
Nursing contact hours can be co-provided by the School of Nursing Must have a nurse for every phase of
planning and implementation in order to get approved for Nursing credits. Catherine Slinkard, SLU
SON Nurse Educator will act as your nurse planner for your activity. You can also have nurses on
your committee to help with planning and implementation, presentation etc….
Social Work credits can be provided by the School of Social Work Must have a social worker for every
phase of planning and implementation in order to get approved for SWcredits.
PLEASE LIST WHAT CREDITS YOU ARE SEEKING for this activity target audience. (Do not request
credits if the above criteria in red have not been met.)
____________________________________________________________________________________
Budget:
Attach your program budget. List all sources and amounts of income anticipated and itemize general expenses
including faculty travel and honoraria. Post-activity financial reconciliation is required (document template will
be provided once application is approved). Expenses will need to be backed up with invoices or receipts.
Funding: Sources of funds:
*Internal Funds
Tuition Fees
Commercial Contributions*
Exhibitor Fees** Other (Grant,etc.): ________________________________________________
If Internal SLU department funds include an email with permission from your department head stating you have
permission to use the funds to cover expenses for this activity.
*A Commercial Letter of Agreement (LOA) is required in advance for all industry supporters. Please refer to
the Policy for Commercially Supported Activities to insure compliance with guidelines. We are unable to use
contributions without the Letter of Agreement (LOA) approved and signed by all parties prior to the activity.
Contributors must not be listed as supporters or attend the meeting without the fully executed LOA.
** Exhibit Space Agreement (ESA) must also be in place. No one can set up an exhibit without prior
approval. The agreement must be approved and fully executed prior to the start of the activity. Exhibit space is
not contingent upon a grant for educational support. If a company gives an educational grant they still are
required to complete the required documents and pay for exhibit space. Ethical business practice, all parties
should pay the same amount for exhibit space unless you outline why fees are different (high traffic, low traffic,
one day exhibit vs. two day exhibit etc…) If activity held on SLU campus then the SLU template for exhibit
space must be completed. If the activity is held off campus and the joint sponsor is setting up the exhibit space
then the agreement for exhibit space should be between the joint sponsor and the company not with SLU.
Regardless of whom the parties are on the form the exhibitors are still required to follow the guidelines set forth
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
by the ACCME regarding not blocking the entrance to the educational activity, not handing out or placing
advertisement with in the educational area, and not forcing a participant to listen to a promotional lecture.
Both forms can be found on the SLU CME website. Only three persons in the School of Medicine have
signature authority to sign LOA’s and ESA’s. As noted on the forms signature authority is according to the
dollar amount of the grant. When downloading the forms please make sure to choose the correct one. All LOA’s
and ESA (exhibits on SLU Campus or directly sponsored by SLU) must be routed to the SLU CME office for
review and routing to the correct approver.
All expenses relating to the CME activity must be tracked with invoices, receipts, and or justification.
Commercial Support companies can audit the use of funds for up to four years after the close of the activity.
The CME office will require complete close out and documentation for the CME activity file from joint
sponsors and SLU departments. If the SLU CME office fully manages the activity we will track expenses and
complete the close out of financial information otherwise it will be your responsibility. Failure to provide the
required information will put the activity into non-compliance and will determine future activities approval.
Post financial form will be sent as a tool for reporting and collection of expense documentation.
AMA PRA Credit Levels
Please check the level you are planning your activity for:
□ Verification of attendance: The physician attended and completed the course.
□ Verification of satisfactory completion of course objectives: The physician satisfactorily met all
specified learning objectives.
□ Verification of proctor readiness: The physician is "proctor ready," which subsumes levels 1 and 2 and
asserts the physician can successfully perform the procedure under proctor supervision.
□ Verification of physician competence to perform the procedure: Competence asserts the physician can
successfully perform the procedure without further supervision.
The AMA website has outlined the requirements (activity format, activity structure, facilities, preceptor,
curriculum, documentation, testing) for each level. Please visit website for more information:
http://www.ama-assn.org/ama/pub/education-careers/continuing-medical-education/physicians-recognitionaward-credit-system/cme-help/guidance-new-procedure-cme.page
Geographical range for mailings: □ Internal □ Local (St. Louis Metro)
□ Regional (150 mile radius of St. Louis) □ Other:
□ Bi-State Area (MO/So. IL)
Source of Mailing List: □ Mailing list broker □ SLU Departmental List
□ Other:
Estimated Attendance:
SLU Physicians:
Total expected attendance:
Other Physicians:
Residents/Fellows:
Others:
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Notes regarding other attendees:
Tuition Fees:
SLU University and Hospital
Physicians: $______________________
SLU Fellows and Residents: _____________________
SLU Nurses: $ ___________________________
Non-SLU Physicians: $_____________________
Non-SLU Fellows and Residents:$_______________
Non-SLU Nurses $________________________
Other: $ ______________________________________________
Program Draft:
Attach a copy of your preliminary program including schedule, topics, faculty and credentials for initial review
and approval. Your finalized program agenda (timeframe, topics and faculty) must be provided to the CME
office a minimum of 3 months prior to the event or credits may be denied.
____________________________________________________________________________________
Evaluation and Outcomes Measure:
Ask yourself or your planning team the following questions. If you cannot come up with the answer then you
need to rethink why you are providing the education and what the achieved outcome will be.
“What will you (the learner) change after attending this educational activity to improve patient outcomes?”
“Have you learned a new tool or competency (strategy) by attending this educational activity?”
The above questions are samples to help you tie the identified gap to the desired outcome. Your team will need
to determine what question to include on the evaluation or follow up questionnaire in order to achieve your
desired outcomes measure.
Check the level you want to achieve through your educational intervention:
□ Level 1: Reaction: Extent of participation and acceptance by the Learner
□ Level 2: Learning: Acquisition of new skills and knowledge by the Learner
□ Level 3: Behavior: Changes in Learner’s clinical practice
□ Level 4: Results: Changes in patient health outcomes
□ Level 5: Changes: Changes in population health outcomes
Planning Notes:
Please keep copies of notes pertaining to content, faculty selection, and format of educational activity to
demonstrate all planning was done independent of commercial interests.
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Specify the educational or professional practice gap(s) that underlies the objective(s) that the activity will
address. The “gap” is defined as the difference between the current state of knowledge, skills, competence,
practice, or patient outcomes and the ideal or desirable state.
Provide proof of how you identified the gap (attach surveys, hospital data, new product sheets, etc)
List the titles of the attached data and state how they prove there is need for this education.
Desired/ideal state of knowledge, competence, performance, clinical/patient outcomes
List what you want the participants to achieve as a result of the education you provide; include desired
measurable data outcomes, if available.
COURSE OBJECTIVES: (so the learner will know what they are going to learn and if it fits into their scope
of practice) What will the participant learn (take back to practice) from the tools or strategies that I teach during
my presentation.
How to write an approved objective:
Examples of approved structure of learning objectives:
At the conclusion of this activity, participants will be better able to:
 Integrate clinical imaging into their practices for diagnosis of neuropathic strabismus
 Manage patients with craniostenosis from birth to adulthood, and predict and treat the potential ocular
adverse sequelae
 Assess which patients are better suited for each type of cataract surgery
 Identify ptosis and eyelid abnormalities in adults and perform new blepharoplasty surgical techniques to
correct ptosis
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
When writing your objectives please avoid the following terms (they are not measurable outcomes):
• Appreciate
• Comprehend
• Internalize
• Recognize
• Be acquainted with
• Enjoy
• Know
• Remember
• Be aware of
• Grasp the
significance of
• Learn
• Sympathize with
• Be familiar with
• Increase interest
• Perceive
• Understand
Suggested/ Approved Terms
• Adjust
• Articulate
• Classify
• Convey
• Diagnose
• Distinguish
• Hypothesize
• Infer
• Organize
• Prioritize
• Relate
• Apply
• Assess
• Compare
• Create
• Diagram
• Employ
• Identify
• Integrate
• Plan
• Produce
• Select
• Appraise
• Categorize
• Conduct
• Demonstrate
• Differentiate
• Evaluate
• Illustrate
• Interpret
• Predict
• Recognize
• Solve
• Arrange
• Choose
• Construct
• Develop
• Discriminate
• Fomulate
• Implement
• Manage
• Prepare
• Recommend
• Use
COURSE OBJECTIVES
Write objectives that relate to the gap information that has been identified and can be measured for outcomes
reporting for change in knowledge, skills, competence, practice, or patient outcomes.
Considering socio-economic, racial, religious, and cultural disparities, will your educational activity be planned
to improve equity in healthcare? (GOAL: All people treated with the highest quality of care. ) ___ yes ___ no
If yes, please explain how your educational activity will identify and address issues to diversify and eliminate
disparities?
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
As per recently approved ACCME (Accreditation Council for Continuing Medical Education) guidelines, we
are required to report the following for each CME-approved activity. Please make sure you have evidence to
back up your planning that pertains to the competencies listed below.
This activity was developed in the context of which competencies; please check all that apply:
ACGME/ABMS
□ Patient Care and Procedural Skills
□ Medical Knowledge
□ Practice-based learning and Improvement
□ Interpersonal and Communication Skills
□ Professionalism
□ Systems-based Practice
Institute of Medicine
□ Provide patient-centered care
□ Work in interdisciplinary teams
□ Employ evidence-based practice
□ Apply quality improvement
□ Utilize informatics
Interprofessional Education Collaborative
□ Values/Ethics for Interprofessional Practice
□ Roles/Responsibilities
□ Interprofessional Communication
□ Teams and Teamwork
Other Competencies
□ Please check if competencies other than those listed were addressed
Provide a list of these here:
__________________________________________________________________________________________
DO not send the application to the CME office if all of the required fields (yellow highlights) and the below
check list has not been initialed for completion.
Check List: (make sure all items are completed and attached or the application will be sent back for
corrections)
______ Continuing Education application reviewed and discussed with planning team
______ Application signed and dated by course director
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
Required attachments
_____ proof of needs assessment (surveys, articles, evaluations, expert opinion, etc…)
_____ budget estimates for expenses and income
_____ schedule/outline with time frames including welcome remarks, breaks, lunch, breakout sessions
_____ Complete the Combination Biographical/Conflict form
Please make sure to check that all questions/sections are completed on both the disclosure and content
validation forms prior to sending to the CME Office.
When above check list is complete the course director(s) should sign and date. If questions regarding the
application are unresolved please contact the CME office for further discussion.
CME@SLU.edu or Phone: (314) 977-7401
COURSE DIRECTOR’S SIGNATURE (REQUIRED):
Signed:
Date:
Print Name:
Email complete packet to: CME@slu.edu or mail to the CME Office (faxed applications will not be reviewed)
SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE
Young Hall
SLU CME Office
3839 LINDELL BLVD., ST. LOUIS, MO 63108
DO NOT WRITE BELOW THIS LINE
DATE RECEIVED:
Initial Review by:
Date:
□ Recommend for Approval □Approval with Changes
□Disapproved/Incomplete
COMMENTS:
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2015-2016 Application CME/CE approval Revised form 1/2015
SAINT LOUIS UNIVERSITY
Continuing Medical Education Application
Application for Approval of CME Certificates
For Live and Enduring Material Activities
REVIEWED AND APPROVED
DATE
L. James Willmore, M.D.
Associate Dean, Saint Louis University School of Medicine
SLU CME Program Accrediting Director
Activity Title _____________________________________
Date of Activity___________________________________
Date entered into PARS report ______________________
Date entered into CME database ____________________
Activity code as assigned in database ________________
Please reference activity code on all promotional and course materials. This code will be used on the AMA
certificates for designation of continuing education audits.
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2015-2016 Application CME/CE approval Revised form 1/2015